The choice, and who it is open to

The NHS: "you can choose to give birth at home. This is usually only recommended if you have a straightforward pregnancy, and both you and the baby are well." NICE frames it as a right rather than a concession: "explain to both multiparous and nulliparous women that they may choose any birth setting (home, freestanding midwifery unit, alongside midwifery unit or obstetric unit), and support them in their choice of setting wherever they choose to give birth."

NICE's opening line on the whole question is worth keeping in view: "explain to both multiparous and nulliparous women who are at low risk of complications that giving birth is generally very safe for both the woman and her baby."

The numbers, if you have given birth before

This is the straightforward case. The NHS: "if you've had a baby before, a planned home birth is as safe as having your baby in hospital or a midwife-led unit."

NICE's table for low-risk women who have given birth before, expressed per 1,000 women by planned place of birth (home first, obstetric unit second):

Spontaneous vaginal birth: 984 at home, 927 in an obstetric unit.
Birth with forceps or ventouse: 9 at home, 38 in an obstetric unit.
Unplanned caesarean birth: 7 at home, 35 in an obstetric unit.
Epidural or spinal: 28 at home, 121 in an obstetric unit.
Episiotomy: 15 at home, 56 in an obstetric unit.
Transfer to an obstetric unit during labour: 115 per 1,000.

And for the baby: "babies with serious medical problems" are 3 per 1,000 for a planned home birth and 3 per 1,000 for a planned obstetric unit birth. NICE's conclusion is that "there are no differences in outcomes for the baby associated with planning birth in any setting."

The numbers, if this is your first baby

Here the picture changes, and the NHS states the change directly: "if you're having your first baby, home birth slightly increases the risk of serious problems for the baby — including death or issues that might affect the baby's quality of life — from 5 in 1,000 for a hospital birth to 9 in 1,000 for a home birth."

NICE's own summary is "about 4 more per 1,000 births" compared with planning birth in other settings. Its table shows 9 per 1,000 babies with serious medical problems for a planned home birth against 5 per 1,000 for a freestanding midwifery unit, an alongside midwifery unit or an obstetric unit.

NICE explains what "serious medical problems" covers: neonatal encephalopathy and meconium aspiration syndrome are the most common, together accounting for 75% of events; stillbirths after the start of care in labour and death in the first week accounted for 13%; fractured humerus and clavicle were under 4%.

The intervention figures for first babies, per 1,000 (home, then obstetric unit):

Spontaneous vaginal birth: 794 versus 688.
Birth with forceps or ventouse: 126 versus 191.
Unplanned caesarean birth: 80 versus 121.
Epidural or spinal: 218 versus 349.
Episiotomy: 165 versus 242.
Transfer to an obstetric unit during labour: 450 per 1,000.

That last figure deserves emphasis. For a first baby, close to half of planned home births transfer during labour. A freestanding midwifery unit is 363 per 1,000. NICE's own advice for first-time mothers reflects this: a midwifery-led unit is "associated with a lower rate of interventions and the outcome for the baby is no different compared with an obstetric unit", whereas planning birth at home carries "a small increase in the risk of an adverse outcome for the baby."

Pain relief at home

One option is off the table. The NHS: "epidurals are not available at home, but you can use gas and air, a warm bath, a birth pool, TENS and any relaxation techniques you've learned." NICE says the same from the service side — epidural analgesia "is available only in obstetric units so transfer will be necessary if she is in another setting."

Opioid injections are available: NICE requires pethidine, diamorphine or other opioids to be available in all birth settings.

What the NHS says you gain

Its list: being in familiar surroundings where you may feel more relaxed; not having to interrupt labour to travel; not needing to leave other children; not being separated from your partner after the birth; a greater chance of being looked after by a midwife you already know; and, if your pregnancy is low risk, a lower likelihood of intervention.

And what it says to consider: you may need to transfer; epidurals are unavailable; and your doctor or midwife may recommend hospital — for twins, or a breech baby, for example.

The questions to ask

The NHS lists four, and they are the right four: how long would it take if I needed to be transferred to hospital? Which hospital would I be transferred to? Would a midwife be with me all the time? How do I get a birthing pool? NICE expects you to be given transfer information in advance if you choose home or a midwifery unit.

Why the US position is different

ACOG starts from the same right to choose — "yes, you have the right to choose where you will give birth" — but reaches a different default: "ACOG believes that the safest place for you and your baby during labor, delivery, and the time after birth is a hospital or accredited birth center."

Its committee opinion gives the figures behind that. Planned home birth "is associated with a more than twofold increased risk of perinatal death (1–2 in 1,000) and a threefold increased risk of neonatal seizures or serious neurologic dysfunction (0.4–0.6 in 1,000)." It also names three absolute contraindications: "fetal malpresentation, multiple gestation, or prior cesarean delivery."

ACOG is explicit that context drives the difference. It notes that the reassuring international data come from "planned home births within tightly regulated and integrated health care systems, attended by highly trained licensed midwives with ready access to consultation and safe, timely transport", and that "these data may not be generalizable to many birth settings in the United States where such integrated services are lacking." Its transfer figures are in the same range as NICE's: 23–37% for first-time mothers, 4–9% for those who have given birth before.

So the two positions are not really contradicting each other on the evidence. They are describing different maternity systems.

Benefits ACOG does acknowledge

"Studies have shown that women who plan to give birth at home are less likely to have infections and tears in the vagina or perineum. They may also have fewer serious tears", along with less induction, electronic fetal monitoring, episiotomy and caesarean birth. For those wanting a low-intervention birth, it points to accredited birth centres and midwife-led hospital care as alternatives.

Freebirth is a different thing

The NHS distinguishes a planned home birth with a midwife from an unassisted birth, or freebirth, and asks you to talk to a midwife first either way. One administrative point catches people out: "by law every birth in England needs to be recorded (notified) within 36 hours", and your baby's NHS number follows a check by a midwife, health visitor or GP.

Wherever you land, the NHS's closing note applies: "you can change your mind at any stage of pregnancy."

Home Birth